Hidden cost drivers in workers’ comp claims can quietly erode your loss ratio, here is how to spot them fast. As we all know, in workers’ compensation, the difference between an acceptable loss ratio and a disastrous one often hides in plain sight within your claims files. While most adjusters focus on obvious red flags like overtreatment or surgical authorizations, the real cost bleed happens quietly through systemic inefficiencies and…
Why Evidence-Based Medicine Reports Are Essential in Workers’ Compensation Claims In the complex ecosystem of workers’ compensation healthcare, the relationship between clinical documentation and claims accuracy has never been more critical. Claims professionals now rely heavily on evidence-based medicine, skilled physician reviewers, and well-supported clinical citations to ensure that every claim reflects true medical necessity. These tools help safeguard injured employees, reduce inappropriate care, and protect organizations from costly errors…
When a claim lands on your desk, intuition is not enough. In today’s complex workers’ comp ecosystem, defensible decisions require evidence, not opinion. As medical treatment grows more complex and costs continue to rise, Evidence-Based Medicine (EBM) reports have become one of the most valuable tools for achieving timely, fair, medically defensible, and well-supported claim decisions. No longer would the axiom “because I said so” be employed as the standard.…
What Is Liberal Construction in Workers’ Compensation Law? In any number of situations, a determination of the fine point is made, and we are wondering, “How the heck was that determination made?” A written statute, rule, or previous decision can fall victim to the nuances of the English language. Dating back to 1928, the legal concept of liberal construction was coined. Liberal construction allows many state statutes, particularly workers’ compensation…
I have always been a visual learner. Watching how to conduct a specific procedure was much easier for me than reading about it. I have taken on this challenge of producing a written blog on a weekly basis, attempting to elevate the skill set of those who consume this material. I have come to learn that writing is so much more difficult than speaking. When we speak, there are facial…
Experience and Perspective in Workers’ Compensation For the record, I have been providing cost-containment services to the workers compensation ecosystem for more than 30 years. At times, I must admit that my serum cynicism level is off the charts. But then again, I get to see those cases that have become problematic and that most of the files being straightforward people seeking straightforward answers to the compensable injuries sustained. The…
Understanding the Misuse of the Term “Concussion” What a great question, if I do say so myself. In my more than three decades of providing cost-containment services from a clinical perspective to those Worker’s Compensation professionals, one frustration is that each time somebody takes a slight (or minor) impact to the head, this is described as a “concussion.” In our Worker’s Compensation ecosystem concussion has become synonymous with any head…
Show Me the Money: The Core Truth of Workers’ Compensation In the world of Worker’s Compensation, there is one absolute truth; and to quote from Jerry Maguire, “show me the money.” Those who have been reading my blog understand that it is my position that all appropriate care should be delivered to the injured employee. You as the claim file handler need to be an advocate for the injured employee. However,…
The Growing Concern: PTSD in Worker’s Compensation Claims A diagnosis that is occurring with increasing frequency is post-traumatic stress disorder, a.k.a. PTSD. This specific diagnosis is a mental health malady that has very specific criterion before it should be applied in every scenario. The media has outlined a modification to the standards, and several state jurisdictions have expanded the definition with particular attention to “first responders” and this becomes a…
As seasoned Worker’s Compensation professionals, and even for those of you who have just joined our little party, you are all aware of the crucial role you play in effectively managing claims, ensuring fairness to all parties concerned, and each of the identified stakeholders. It has been my experience, as someone who has run a cost containment concern for the Worker’s Compensation ecosystem for more than three decades, those who…
